Provider Demographics
NPI:1174843197
Name:SHAKESPEAR, JEREMIAH (DDS)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:SHAKESPEAR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 EXCHANGE ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-3508
Mailing Address - Country:US
Mailing Address - Phone:503-325-3533
Mailing Address - Fax:503-325-3609
Practice Address - Street 1:1775 EXCHANGE ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-3508
Practice Address - Country:US
Practice Address - Phone:503-325-3533
Practice Address - Fax:503-325-3609
Is Sole Proprietor?:No
Enumeration Date:2010-06-02
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9903122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist